Prostate cancer can be discovered at an indolent stage, not involving the vital or functional prognosis of the patient.
In the case of indolent prostate cancer, the immediate active treatments might not be appropriate due to many side effects induced without enhancing patient’s survival or quality of life.
ACTIVE SURVEILLANCE could be an interesting option in case of indolent prostate cancer, with the following caveats:
- Patient must take all the precautions to confirm PROSTATE CANCER indolence and lack of development over time;
- Medical team must ensure that patient fully understands and adheres to this medical care modality.
- Clinical: Digital rectal examination (DRE),
- Biology: The prostate-specific antigen (PSA) rate in blood and its variations,
- Imaging: Ultrasound and especially multi-parametric MRI.
What is the “ACTIVE SURVEILLANCE “?
ACTIVE SURVEILLANCE consists of delaying active curative treatment in patients with localized prostate cancer characterized by low risk of progression, while patient’s life expectancy is above 10 years. Therefore, ACTIVE SURVEILLANCE is opposed to ‘Watchful Waiting’ approach that consists of an abstention of treatments for incurable patients with palliative treatments implemented when symptoms are observed.
However because of the risk of misdiagnosis (prostate cancer wrongly diagnosed indolent) as well as potential growth risk over the years, especially when patient diagnosed is a young patient, a well codified ACTIVE SURVEILLANCE should be organized for several years and the patient should be prepared to consider an active treatment as soon as the surveillance indicators suggest a revision upwards of the cancer extension risk. The ACTIVE SURVEILLANCE approach is totally integrated to prostate cancer curative treatment arsenal: it consists of delaying the time where active therapies (surgery, radiotherapy) will step in.
Toronto University Hospital care team started offering ACTIVE SURVEILLANCE protocol to suitable patients for over 15 years with encouraging results: 97.2% survival rate with a median follow-up of 6.8 years over a 450 men cohort.
Important to notice that 30% of these patients were reclassified at higher risk levels leading to active treatments. This proportion of ~ 30% is established throughout most of ACTIVE SURVEILLANCE research programs, underlining the importance of confirming “low risk” status and monitoring it over-time.
When to use active surveillance?
In a man (up to 75 years of age), a set of criterias must be assessed to determine the cancer indolence and allow the urologist to advise ACTIVE SURVEILLANCE rather than curative treatments:
– A PSA level of less than 10 ng/ml,
– No tumor diagnosed through DRE,
– A tumor whose dimensions do not exceed 10 mm on MRI,
– Gleason score < 7 (no grade 4),
– Biopsy must collect at least 10 cores while none should be diagnosed with tumor length of 3 mm or more,
– A maximum of 2 positive cores,
– Patient with life expectancy of + 10 years,
– The patient accepts ACTIVE SURVEILLANCE protocol and thus waives immediate treatment. In some cases, patient might prefer to start the traditional care process to avoid any risk of cancer extension.
What is active surveillance protocol?
To avoid misdiagnosis risks (tumor wrongly diagnosed as indolent), a confirmation biopsy is required 3 to 12 months after the first biopsy.
The protocol includes periodic biopsies (every two years) and clinical tests (DRE) as well as biological ones (PSA) at regular intervals, every 6 months.
Integration into the protocol of MRI instead of biopsies is under consideration, due to fact that biopsies are often causing anxiety that might remain an obstacle to the protocol acceptance.
When should Active Surveillance be abandoned for treatments?
A stable tumor might progress at any time, imposing a strict monitoring of untreated patients. The urologist will evaluate the situation and present it to the patient in light of examination findings.
If situation remains stable, the urologist will propose ACTIVE SURVEILLANCE to be continued.
Otherwise, if the tumor shows signs of scalability, prostate cancer curative treatments will be advised, being attentive to patient’s preference.
The oncological results of men enrolled in ACTIVE SURVEILLANCE but had to abandon it for radical prostatectomy, are identical with results seen for men who went through the surgery right away after cancer diagnosis.
Some bibliographic elements :
Prostate cancer screening (French)
French protocol of the French Association of Urology (FAU)
Short description of ACTIVE SURVEILLANCE protocol